Authorization Request for
Day Treatment or Partial Hospital Program
Click here to open and print or save the Authorization Request for Day Treatment or Partial Hospital Program form.
This request is to be used for NEW AND CONTINUING SERVICES for a client. Treatment plan must accompany this request.
Please print clearly. Incomplete or illegible forms can not be processed.
Please fax completed forms to TEAM at: 651-642-1809
Adobe's Reader software is required to open this form. If you need the software, it is freely available from Adobe: Adobe Reader